HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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FEE
Board of Health, y&2MD\Y-[V , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) rp!�>
) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
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Owner's Name
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address po
Address
Telephone#
Telephone#
Type of Building 40 ma 6k. Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers O , Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow providedgpd
Plan: Date Number of sheets Revision Date
Title
.Description of Soils)
Soil Evaluator Form No. Name of Soil' Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ►7 " k b Y 4-f n 4111 /14 - J /'a. n � d
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5' and
further agree o not to place the system in operation until a Certificate of Co ipliah a has been issued by the Board of Health.
Signed Date
Inspections l C / S G �� t3 (i x `
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COMMONWEALTH OF MASSACHUSETTS,
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ndividuat Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed J I, Repair O,Upgraded ( ),Abandoned ( )'
by:at
has been installed i} acc roan e with the provisions of ,0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. l . dated 17-/- Approved Design Flow (gpd)
Installer`s ,
Designer: ; -464 - - Inspector: Date: 1 ! l s=
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
1 FEE.
COMMONWEALTH Of MASSACHUSETTS i
Board of Health, �f %1 OQT1 + , .MA. 0 � �✓�
DISPOSAL. SYSTEM CONSTRUCTI®NT PERMIT
Permission is hereby granted to Construct( ) ) Upgrade( ) Abandon( ) an indh dual sewage disposal system
at as described in the application for
,r
Disposal System Construction Permit NO. Nw , dated % t
Provided: Construction shall be completed'within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5l96 A.M. Sulkin Co. Charlestown, MA Date h�Board of Health /� "'